Hot Seat #56: 14 yo w/ severe abd pain, recent URI
Posted on: May 7, 2015, by : Lenore Jarvis MD MEd
by Lenore Jarvis, Children’s National
with Shilpa Patel, Children’s National
The Case
14 year old prev healthy male presenting with severe LUQ pain in the setting of a recent URI. Patient and mom report he had chills/fevers that started “last week”, then got better. Last week, the patient also had URI symptoms including cough, mild shortness of breath and chest pain. These symptoms completely resolved x 1 week.
Today, he presented to the ED after waking up feeling weak and with sharp, severe LUQ pain (no radiation, no exacerbating/relieving factors). He complains that his whole body hurts/aches, including his middle and lower back. Hasn’t wanted to eat or drink anything due to nausea. He also had a headache that went away.
Patient denies any diarrhea, dysuria. He also denies any recent trauma. Patient reports having intermittent tactile fevers – unmeasured at home. No sick contacts at home or school.
ROS: No changes in vision. Feels very weak. Throat pain. Muscle aches. SOB and chest pain last week. No joint pains. No rashes.
PMedHx:- Concussions x3.
PSurHx: – none
FamHx: – none
SocHx: -plays football. Lives in a wooded area. Sexually active with condoms. No recent travel
PE: 38.8C, HR 111, 121/69, RR 22, 98% RA
General: Anxious. Agitated. Appears to be in pain.
Skin: Warm. dry. No rashes.
Ears, nose, mouth and throat: Oral mucosa moist. Throat: moderate erythema, no exudate, no swelling.
Neck: Supple. trachea midline. no tenderness. Lymphadenopathy: mild shotty cervical LAD.
Cardiovascular: Tachycardic, regular rhythm
Respiratory: Lungs are clear to auscultation
Gastrointestinal: Soft no abdominal distention. Tenderness: left flank and left upper quadrant. Guarding: minimal. Rebound: negative. Bowel sounds: normal. Organomegaly: spleen 2 cm below costal margin.
Genitourinary: Normal genitalia for age
Back: left flank TTP, no pain anywhere else
Musculoskeletal: Diffuse muscle tenderness
Neurological: No focal neurological deficit observed
Urine testing and bloodwork are sent.
You give 4 mg IV morphine x 1 dose with minimal relief: patient is still writing in pain and unable to lie still. Urine dip is negative.
Questions for you:
Re-examination
The patient received a NS bolus x2, motrin for fever, and morphine x2 (which improved pain from 8 to 6 of ten).
CBC showed a WBC count of 16. CMP and lipase were negative. CK was increased to 173. UA negative. Orasure negative.
The patient was rapid strep positive. He was monospot negative.
AXR showed a non-specific bowel gas pattern.
The patient is now afebrile, HR 92, continuing to report LUQ abd pain of 6/10 and is now able to lie still. He does still appear uncomfortable despite the morphine.
Abdominal is unchanged: LUQ TTP, no rebound, guarding, or other TTP.
You think he needs admission due to pain. The Bed Czar requests a surgical consult.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
An admission “for pain control” without first elucidating the etiology for the pain in the ED is a classic ED physician “cop out” (akin to “the hedge” by Radiologists). This is an adolescent male who comes in with a likely pathological source of real pain in his LUQ (he’s been ill, is febrile, is tachycardic, has severe LUQ abdominal pain, is writhing in pain, and has splenomegaly on examination). This kid shouldn’t leave the ED until we’ve figured out what’s causing his pain. He needs better abdominal imaging than just an AXR. Things to strongly consider include spontaneous splenic rupture from Mono (despite the negative Monospot test, which becuase of its poor sensitivity is only really useful when positive), splenic abscess, some other infiltrative process of his spleen, or maybe an issue with his left kidney (but UA was negative). I’d definitely start with an ultrasound. And, if I was the attending on this case, this kid would likely also get an abdominal CT (with IV and maybe PO contrast) before his ED stay was over.
Great points Dewesh! In this case, ultrasound was not available for >12 hr unless called in as an emergency.
Maybe I missed it but i didn’t see a CXR in there. LL pneumonia is classic with abdominal pain.
But so are other intra-abdominal pathologies such as psoas abscess, liver abscess, perf’ed appy partially treated with amox for an otitis he never had, etc.
Fever/splenomegaly is a discussion……..yes send EBV/CMV titers. probably not mono with the normal transaminases and negative monospot. But titers are better. There are a host of other infectious, neoplastic, and inflammatory diseases that cause fever and splenomegaly. a better exposure history is helpful here (pets, animal farms, undercooked foods, etc). histo, toxico, HIV, etc. i would get coags here to look at liver function in the presence of true splenomegaly without obvious (mono) source. would be nice to document a liver edge.
I’m a little reassured that the albumin is normal as well as the transaminases. I definitely have seen kids with cardiomyopathy and CHF present with abdominal pain, but should have a liver edge and ascites with hypoalbuminemia. Most potentially bad diseases will drop your albumin unless very acute. So a normal albumin makes me think this is less likely a truly systemic disease like leukemia, HIV, etc.
Agree with Dewesh, you can’t admit for pain control when you don’t at least have a “working” diagnosis. ok if some tests are pending and you have a suspicion, but it’s a little silly to admit with no working diagnosis. The child can’t leave the ED without some form of abdominal imaging and a CXR.
The fever and elevated white count point most to an infectious process, though malignancy and autoimmune diseases are also possible. Along with the usual suspects of EBV and CMV, a complicated pneumonia fits with the history of a URI and cough the week before and explains his current symptoms (except for the suddenness of the pain). This child needs more imaging to better understand what is going on before admitting. Start with a CXR to make sure there isn’t a massive effusion with pneumonia, or even a sympathetic effusion from the splenic process, that could lead to respiratory distress in the near future.
Then move to abdominal US: the questions to answer include—is the splenic enlargement homogeneous or focally abnormal suggesting an abscess or infected hematoma from football; is the liver enlarged or normal in size and appearance; and importantly, does the splenic vein have normal flow or is it thrombosed to explain the isolated splenic enlargement.
The decision of additional imaging with a CT with contrast can be made after these intial studies focus the differential better.
I agree with above and would not send the patient to the floor without more diagnostic work up. CXR should definitely be ordered and an Abd CT with contrast (if US is not available for 12hrs) is reasonable. I am also thinking infectious given the fever and elevated WBC but oncologic or splenic rupture (as mentioned above) is also on my differential.
Hot Seat Response…
I appreciate and agree above comments by Dewesh, Dave, Jennifer and Joelle. Our case is an adolescent male with severe LUQ pain who has fever, tachycardia and an abnormal abdominal exam – a large tender spleen! As Dewesh points out, this child is sick – we need to investigate. Never ignore the tachycardic teenager!
Thanks to Jennifer, Dave, Dewesh and Joelle who have already outlined a nice differential for left upper quadrant pain. Here is a summary plus a few others:
• DDx of entities that present with acute severe LUQ pain: acute splenic rupture, (HIV, mono) splenic ischemia, renal colic(would not explain the fever or the splenomegaly though); (way out there…but possible → acute appendicitis with malrotation)
• DDx of fever and splenomegaly: Mono (yes…a negative monospot does not rule out disease and normal liver enzymes are reassuring against EBV), CMV, HIV, tick borne illness, splenic abscess; I also like Jennifer’s thought of a pneumonia with effusion, pushing the spleen down (though there is no hypoxia, normal lung auscultation)
• DDx of cardiac cause— pericarditis, CHF or myocardial ischemia (though not usually a large spleen with this one) can present with acute LUQ pain
• Infiltrative splenic process
• DDx intraabdominal process – pancreatitis (would expect abnormal amylase and lipase); mesenteric infarct
Just a few thoughts on why this could still be acute retroviral syndrome…we have a sexually active male with recent “URI” illness coming in with a mono-like illness
1. The Orasure is negative in acute HIV and does not rule it out. The “window” period where the Orasure can be negative is up to 3 months and a patient typically present with signs and symptoms of acute HIV (fever, myalgias, arthralgias, rash, pharyngitis, headache…) within the first 2-4 weeks of exposure.
2. Acute HIV resembles mono, flu, strep, viral hepatitis, toxo, syphilis….and can present with bacterial co-infection (lung, splenic abscess, etc)….
3. CMP can sometimes show elevated total protein relative to albumin (not sure if you would have a low albumin this early in HIV)
4. Usually with lymphopenia, anemia and thrombocytopenia….not always – again not sure when during course of illness this occurs.
Imaging….if US is not available with our patient writhing in pain, I would consider abdominal CT.
Looking forward to the morning discussion!